TTuberculosis is the leading cause of morbidity and mortality among people living with HIV; yet uncoordinated clinical care imposes heavy burdens on co-infected patients. In Eswatini, task shifting and the decentralization of TB and HIV treatment services to primary health centers allowed for TB/HIV integrated service delivery, or a ‘one stop shop’. These health system changes resulted in a 28 percent increase in ART initiation of co-infected patients between 2012 and 2017 and in a cohort study, almost 90 percent of TB and HIV co-infected individuals initiated ART within eight weeks per national guidelines. Overall, since implementation began, both morbidity and mortality related to TB have decreased significantly.
Identifying and serving key populations across the HIV cascade is challenged by discrimination and stigma. Through collaboration with KP community-based organizations, innovative strategies using information and communications technologies and social media were implemented to target key populations who do not access HIV services. Through the project’s Online Change Agents, over 1400 clients were referred for HIV testing and a yield of 10.8% was generated from testing this population. The project’s Facebook page has over 230,000 followers and each post reaches an average of 11,000 users, demonstrating the reach of these social media strategies.
In Malawi, men living with HIV are less likely than their female counterparts to be aware of their HIV status, on antiretroviral treatment, and virally suppressed. To address barriers that prevent men from accessing HIV services, the Elizabeth Glazer Pediatric AIDS Foundation designed and opened male-friendly clinics to provide integrated HIV, reproductive health, and non-communicable disease services during times that are more suitable for men; in this case, on Saturdays from 7:30 am-2:00 pm. The resulting mean HIV positivity rate at male-friendly clinics is 5 percent, with yields as high as 15 percent among men aged 35 - 39. Men accessing male-friendly clinics reported being more comfortable in men’s clinics and that Saturdays were more convenient. This suggests acceptability of this service delivery model, which contributed to the improved health outcomes for men.
Mother-baby pairs who do not continually utilize critical integrated maternal, newborn, and child health (MNCH) and HIV services often have poor health outcomes in resource limited settings. The Community Focal Mother (CFM) model in Eswatini has demonstrated success in improving use of and retention in integrated MNCH and HIV services. This includes final knowledge of HIV status of 18-24 month infants, timely vaccination, and provision of mother baby health visits. Trained CFMs visit all mother baby pairs in their homes before they miss a visit to encourage continued attendance at health facilities for care. This model has seen 100 percent retention in services of mother baby pairs since its inception in 2017; all children have completed their child welfare visits per the Ministry of Health recommended schedule and received key integrated HIV and MNCH services.
Voluntary medical male circumcision (VMMC) is an evidence-based prevention approach that can reduce HIV transmission. However, sustaining demand and lowering costs of this core intervention can be challenging. In Tanzania, engagement and use of a volunteer community-based cadre of lay workers to promote and create demand for VMMC led to an almost five-fold increase in VMMCs performed in health facilities. This increase was sustained over time, with a cumulative 45,182 VMMCs performed eighteen months after the introduction of this model. Moreover, this model also reduced costs by 13%.
Through the support of the United States Government’s President’s Emergency Plan for AIDS Relief (PEPFAR), Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) introduced comprehensive men’s clinics at selected high-volume health facilities in order to scale-up the Test and Start approach among HIV-infected men. The men’s clinics provide a male-friendly environment that encourages men to get tested for HIV, and therefore be identified as HIV positive and linked to HIV care and treatment services.
Mozambique has demonstrated the feasibility and impact of the use of point of care testing (POCT) for early infant diagnosis (EID), resulting in significantly reduced turnaround times and increased rates of antiretroviral therapy (ART) initiation. Strong partnership between the Ministry of Health (MoH) and other stakeholders was key to successful implementation.
In the Democratic Republic of the Congo (DRC), overall retention rates at the end of fiscal year 2016 (FY16/COP15) were documented to be 69.5%. As the country began transitioning to a Treat All model, many facility staff members were concerned they would be able to keep up with demand, given the ongoing long wait times for stable patients seen monthly in clinics. The Postes de Distribution Communautaire (PODI) plus model is a community-based, individual drug distribution and psychosocial support model. PODIs reduce the workload of overburdened health care workers by decreasing the number of patients individually attending the clinic, whilst maintaining good health outcomes for patients.
In Kenya, adolescents and young people living with HIV (AYPLHIV) account for approximately 20% (303,700) of all people living with HIV (Spectrum Estimates, 2015; Kenya HIV Estimates 2015 Report). AYPLHIV (aged 10-24 years) face especially complex challenges dealing with a chronic illness amidst the physical, emotional and psychological developmental changes of transitioning from childhood to adulthood. The Operation Triple Zero (OTZ) initiative engages AYPLHIV as active stakeholders and partners in their health by promoting a responsive service delivery model.
The establishment of viremia clinics was an initiative to address the gaps and challenges in the monitoring and management of patients with high VL, and function as a form of differentiated care for unstable clients with high VL. Held at least one day a month, the viremia clinic utilizes a multidisciplinary team (MDT) model and focuses on enhanced case management and a patient-centered approach. This model is aimed at identifying patient-specific adherence barriers and tailoring interventions to address the patients’ specific needs. Patients are empowered to make joint decisions with their providers to improve their ART adherence.
Faced with challenges to patient adherence and retention on antiretroviral therapy (ART), Mozambique implemented a community approach to service delivery. This approach provides patients with easier access to their antiretroviral treatment, in addition to peer support.
Because the majority of antiretroviral therapy (ART) services provided in resource-limited settings are done so in standardized yet inefficient ways, long-term ART adherence and retention is difficult. In Uganda, stable clients needed ways to access medications closer to their homes, which would reduce the cost and disruption of remaining adherent to ART.
Ariel Adherence Clubs (AACs) have been implemented across 6 regions in Tanzania, at 105 facilities, since 2007 by the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). AACs were designed to address the social and behavioral barriers to HIV treatment, retention, and adherence faced by children and adolescents. All participants in AACs are required to know their HIV status. As such, trained providers work with caregivers to facilitate disclosure of HIV status to children and adolescents. Psychosocial support groups for HIV-positive children and adolescents aged 5–19 are provided at AACs. Clubs are grounded in the belief that children and adolescents living with HIV (ALHIV) will achieve improved health outcomes when clinical services are complemented by high-quality social support and age-appropriate information about HIV infection, treatment, adherence, HIV status disclosure, positive living, and life skills needed for growing and aging into healthy, HIV-positive adults. The purposes of AACs are to improve participant antiretroviral treatment (ART) adherence and clinic retention, and provide psychosocial supports to adjust to living with HIV and transitioning into adulthood and adult HIV care.
Antiretroviral therapy (ART) is frequently distributed via health facilities and their pharmacies. An increased volume of medically-stable patients at facilities reduces the time clinicians can spend with those who require acute care and also discourages patients from attaining care, due to long wait times. For medically-stable patients, going to a health facility for monthly refill pickup reduces the likelihood of retention on treatment for a variety of factors, including the transportation costs and financial losses of time missed at work incurred by a trip to the health facility . Importantly, retention on ART is vital to the health of HIV-positive individuals, but also to the well-being of the communities in which they live. Achieving higher rates of retention among HIV-positive patients, then, is crucial.
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 patients receive a package of peer-delivered linkage services recommended by the International Association of Providers of AIDS Care (IAPAC), the U.S. Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO). The standard set of linkage-to-care recommendations helps ensure all people living with HIV (PLHIV) enroll in care in a timely manner.
The Western Cape Government Department of Health adopted the adherence club (AC) model for the Cape Metro district in January 2011. The ART-AC model provides patient-friendly access to ART for clinically stable patients, ART distribution, and care and support to groups of stable patients. ACs can reduce the burden that stable patients place on healthcare facilities, freeing healthcare workers to treat new and unstable patients.
Through community-based testing, HIV-infected clients are provided baseline clinical care and a comprehensive package of peer-delivered linkage services recommended by the World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC). CommLink mobile clinical and linkage services initiated at the point of HIV diagnosis are designed to help community clients “link” to a local facility for lifetime HIV, care, treatment, and support.
The Zvandiri program, run by Africaid, began in Zimbabwe in 2004 as a support group for adolescents living with HIV. Community Adolescent Treatment Supporters (CATS), HIV- positive people aged 18-24 years, work between health facilities and the homes of youth living with HIV (YLHIV) to increase uptake of testing, linkage, and retention in care, adherence, and services related to sexual and reproductive and mental health. Monthly community-based support groups, community outreach teams, and clinic-based Zvandiri Centers provide safe spaces for accessing clinical and social services and linking adolescents to other forms of assistance, while educating individuals on sexual and reproductive health (SRH) and life skills. Through these interventions, the Zvandiri program builds mental, emotional, and physical resilience.
In many PEPFAR countries, most funding for a national HIV program comes from the host country. Nevertheless, programs for pecific communities and key populations (KP) remain largely dependent on external donor financing through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund). Local public resources to support the KP response have remained underused due to a shortage of social contracting systems, limited social health insurance capacity, and undefined policy frameworks.
As part of the efforts to scale-up HIV testing services (HTS) and prevention interventions, along with proactive referrals to antiretroviral treatment (ART), PrEP for HIV prevention was formally made available in late 2015. However, there were no data on the acceptability to guide targeting and roll-out. Since PrEP is a relatively new prevention intervention in PEPFAR countries, PEPFAR’s partners will need technical assistance to scale best practices with fidelity and to ensure that implementation addresses the diversity of target populations across varied settings.