What was the problem?
Many HIV-infected persons do not enroll directly into HIV care and treatment following diagnosis, particularly among those diagnosed in community settings. The need to identify effective linkage-to-care and treatment strategies, especially for persons diagnosed in community-based settings is paramount towards achieving the 95-95-95 targets (that is, 95% of all people living with HIV know their status, 95% of all people with diagnoses HIV infection receive sustained antiviral therapy, and 95% of all people receiving antiretroviral therapy are virally suppressed). The need is particularly acute in countries that have a significant gap in reaching and linking men.
What is the solution?
In Eswatini, a package of linkage-to-care interventions similar to the Bukoba Combination Prevention Evaluation (BCPE) implemented in Tanzania was implemented through CommLink, with similar results. The main difference between the two programs is that CommLink is strictly a community-based platform and integrated with a mobile unit that provides point-of-diagnosis HIV care. Tents are also used to provide HIV care services when mobile units are unavailable. Meanwhile, BCPE provides linkage case management for those diagnosed in community and clinical settings.
COMMLINK’S Linkage Case Management (LCM) SERVICES:
Individualized, peer-delivered counseling from HIV-positive, ART-adherent Expert Clients (ECs) trained to provide psychosocial support and HIV informational and motivational counseling;
First-visit escort or transport to an HIV care and treatment facility (same-day, whenever possible)
Treatment navigation services for at least the client’s first facility-based care visit
One same-day and two follow-up face-to-face counseling sessions;
Follow-up support calls and appointment reminders; and
Integrated index-client HTS to support disclosure, and to facilitate testing and linkage-to-care of HIV-infected sex partners, family members, and associates.
KEY PROGRAM FEATURES
Integrated with point-of-diagnosis HIV care provided in mobile units or tents
4 mobile-unit teams staffed with 12 EC counselors and 4 nurses (typically, 2 ECs and 1 nurse staff an outreach event)
HTS provided by 2-4 counselors per outreach event
All services are free for newly diagnosed HIV-positive individuals and HIV-positive individuals who have not received HIV care in >90 days, and consent to the program.
Implemented in Hhohho region (June 2015 – March 2016), Manzini region (March 2016 – present), and Lubombo region (July 2017-present).
The program provides linkage services and documents client outcomes through 90 days (the maximum duration of the LCM period).
What was the impact?
Out of 651 clients of closed cases through March 2017 (MMWR, 2018):
Note: Closed cases include newly diagnosed clients and previously diagnosed clients, who had not been in care for > 90 days, followed by CommLink for 90 days.
629 (97%) received mobile clinic services
621 (95%) were escorted to or met at an HIV clinic and provided treatment navigation support ≥ 1 times
553 (85%) were contacted weekly by phone
608 (93%) completed ≥ 3 counseling sessions
635 (98%) enrolled in facility-based HIV care (half of whom enrolled within 5 days)
399 were males and 236 were females
541 (83%) initiated ART (half of whom initiated within 6 days of diagnosis)
346 were males and 195 were females
90 (66%) clients initiated ART in CD4 <350 era (June 2015 – November 2015)
234 (81%) clients initiated ART in CD4 <500 era (December 2015 – September 2016)
217 (96%) clients initiated ART in Test & Start era (October 2016 – March 2017)
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. Individuals were identified in community-based settings, and provided informed consent to be in the program.
Linkage to care and treatment is diminished by economic, geographic, transportation, and distance barriers, as well as stigma and discrimination, and the emotional process of accepting one’s HIV diagnosis. All of these potential barriers are addressed in the LCM model implemented by CommLink.
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
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. Expert clients could be trained in conducting HIV testing, which could potentially cut down on the number of personnel needed to staff outreaches and conduct index-client testing.
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.
Developing peer navigators and case managers
Prompt engagement in HIV care optimizes individual and public health outcomes. Peer navigators are individuals who assist individual patients to navigate through the continuum of care, ensuring that barriers to care and treatment are resolved and that each stage of care and treatment is as seamless as possible. It is well documented that PLHIV can be trained to effectively 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 and treatment 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 have been used to strengthen patient outcomes throughout the HIV care continuum including early linkage to care and treatment, retention in care and treatment, 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 Eswatini 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 EC counselors and the clinical services initiated in the mobile unit. Finally, the letter requests facility cooperation to:
Designate a point-of-care 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.
SNAP and CDC are currently planning national scale up of the model as a key component to an integrated facility and community testing and linkage strategy. In addition, given the exceptionally high linkage-to-care and treatment rates, SNAP selected the program as a platform to pilot same-day ART in community settings.
A costing analysis is planned for 2018 (pending the availability of COP16 funds). However, in a similar LCM program conducted as part of the Bukoba Combination Prevention Evaluation, the average program cost per LCM client was $54. Personnel costs accounted for 72% of the total program cost for LCM. Per-client LCM costs in Eswatini are expected to be higher because mobile units were purchased to provide point-of-diagnosis CD4 and clinical services, and because expert-client counselor salaries are higher than peer-counselor stipends in Tanzania.
Primary costs include personnel (supervisors, ECs, and nurses), mobile units (or alternatively, tents and associated equipment), and personnel transport (vehicles and public transport reimbursement).
MacKellar D., Williams D., Bhembe, B., et al. Peer-Delivered Linkage Case Management and Same-Day ART Initiation for Men and Young Persons with HIV Infection—Eswatini, 2015 – 2017. MMWR Morb Mortal Wkly Rep 2018; 67: 663-667. DOI: http://dx.org/10.15585.mmwr.mm6723a3
Revised by the PEPFAR Solutions Team, July 2018